Evaluating the impact of quality and safety interventions is an evolving science. While some have argued for a new paradigm in the field, others have advocated for standards similar to clinical trials. This study developed a comprehensive approach and model to increase prophylaxis against venous thromboembolic disease, ventilator-associated pneumonia, and stress ulcers in a single intensive care unit. The model included adoption of tools that promoted team communication, prompts to providers to address the evidence-based measures on a daily basis, and a data wall to provide real-time feedback. The authors provide a detailed description of their efforts that achieved near 100% target goals and advocate for this approach in creating successful microsystems that benefit from their refined Plan-Do-Study-Act methodology.

Handovers, or handoffs, in patient care are a continued and problematic safety concern that were further elevated by The Joint Commission into a National Patient Safety Goal. Despite guidelines and past efforts to standardize the process with computerized tools, there are remaining opportunities for improvement. This study adopted a handover assessment instrument in the intensive care setting to evaluate the degree of information corruption in handover exchanges. Investigators discovered variances in information retained during a handover compared with actual facts from the medical record, and noted the potential for these variations to contribute to errors in care. The authors share their tool and advocate its use as a screening method to identify areas for improvement in the quality of handovers. A past AHRQ WebM&M case commentary discussed a fumbled handoff resulting from poor communication and lack of standardization in the process.

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Addressing handoffs in patient care is a continued challenge, particularly around medication safety. Medication reconciliation was seen as a preventive strategy to handle such concerns, though the lack of proven strategies led The Joint Commission to soften its previous National Patient Safety Goal. A commonly held belief is that electronic health records (EHRs) provide solutions to communicating health information. This study compared medication reconciliation events for patient handoffs within a computerized VA system to a paper-based system outside the VA. Interestingly, there was no significant difference between medication discrepancies and adverse drug events (ADEs) in the highly computerized system. The authors suggest that their findings support a need for specialized tools to facilitate medication review at times of transfer. A past AHRQ WebM&M commentary discussed medication reconciliation after an avoidable error.

Strategies that foster a positive safety culture are increasingly supported by emerging relationships between hospital safety culture and adverse events, such as readmissions. Teamwork training, executive walk rounds, and establishing unit-based safety teams are all initiatives associated with improvements in safety culture measurement. This study describes a hospital-wide initiative that significantly improved nearly all safety culture domains in 144 clinical units over a 3-year period. The initiatives implemented included a comprehensive unit-based safety program (CUSP), specific teamwork and communication tools, a series of educational venues, and investments in infrastructure and leadership positions. A past AHRQ WebM&M conversation and perspective discussed important facets of safety culture in health care.

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Disruptive and unprofessional behavior that goes unaddressed poses a threat to patient safety by hampering development of a culture of safety. This study reports on how one academic hospital addressed this issue by developing a multidisciplinary code of professionalism accompanied by a dedicated hotline for reporting unprofessional behavior. All reported incidents resulted in a combination of feedback, coaching, or disciplinary action for involved providers. Introduction of the code and the reporting system was associated with a significant improvement in teamwork and communication, as measured by the AHRQ Hospital Survey on Patient Safety Culture. This study provides an approach for health care organizations to address the disturbingly common problem of disrespectful and hostile behavior in the workplace. Other approaches are outlined in a PSNet perspective.

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Inadequate supervision of resident physicians has been recognized as a potential patient safety hazard for decades. The Accreditation Council for Graduate Medical Education emphasized the importance of proper supervision in the 2011 duty hour regulations, implementing specific rules mandating closer supervision for first-year residents. However, there remains surprisingly little empirical research on effective supervision models. This qualitative study of residents during an intensive care unit rotation found that the authority gradient significantly affected residents' decisions to seek supervision and feedback from superiors. Residents did report benefiting from nonjudgmental feedback and advice from clinicians from other disciplines, principally nurses and pharmacists. Residents agreed that regardless of discipline, clinicians who used nonjudgmental language were much more effective supervisors and teachers. This study provides a novel perspective on the relationship between safety culture and resident supervision.

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This study used video-reflexive ethnography—a qualitative intervention approach that involves videotaping daily work processes and then using the videos to stimulate further discussion and problem solving—to analyze how clinicians create safe spaces for communication in the busy environment of the intensive care unit.